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Extrapleural Pneumonectomy (EPP)

An extrapleural pneumonectomy (EPP) is an aggressive surgery for malignant pleural mesothelioma that involves removing the cancerous lung and parts of the chest lining (parietal pleura), heart lining (pericardium), and diaphragm in order to control tumor growth. Learn more about EPP and how Mesothelioma Hope can connect you with skilled surgeons in your area.

Medically reviewed by: Mark Levin, MD

Last updated:

Extrapleural Pneumonectomy (EPP) for Mesothelioma

A mesothelioma extrapleural pneumonectomy (EPP) is a type of surgery used for people in the early stages of malignant pleural mesothelioma (MPM).

Some studies have shown that patients with mesothelioma who undergo EPP have a median survival time of up to 35.6 months. This is about 3 times the average life expectancy of most patients.

Many patients who have had EPP have lived much longer. Some people have achieved overall survival times of more than 10 years.

Quick Facts About Extrapleural Pneumonectomy
  • The first EPP was performed on a mesothelioma patient in 1976.
  • Extrapleural pneumonectomies are always performed with chemotherapy and sometimes radiation before, during, or after surgery.
  • Extrapleural pneumonectomy is a potentially curative surgery that has allowed some patients to go long periods without cancer.
  • About 1 in 3 patients who have EPP experience major complications.

The Extrapleural Pneumonectomy Procedure

Extrapleural pneumonectomy is a complex surgical procedure. Only pleural mesothelioma patients who are physically fit enough to withstand surgical complications and recovery are candidates for this mesothelioma surgery.

It is common for patients to receive chemotherapy or radiation therapy in the weeks before the surgery. Researchers are studying whether chemotherapy before surgery or after (adjuvent) is most effective.

Illustration of a person's chest cavity, showing mesothelioma forming in the lining of the lung

Here is what happens during EPP:

  1. General Anesthesia: The patient is given a general anesthetic before the procedure begins.
  2. Surgery: A surgeon opens up the patient’s chest cavity at the front (sternotomy) or on the side (thoracotomy) and makes a nine-inch incision.
  3. Lung and Tissue Removal: Surgeons remove the diseased lung, membranes lining the chest wall, and the diaphragm. They may also remove the sac around the heart (pericardium) and nearby lymph nodes. The surgeons rebuild the diaphragm and pericardium using artificial materials. Great care is taken not to enter the pleural cavity as this can cause cancer cells to spread.
  4. Recovery: Patients often require a prolonged hospital stay to recover as the procedure increases the load on the heart and the remaining lung. During this time, medical staff will closely monitor the patient.

Patient selection is crucial. Only patients in the early stages of mesothelioma who are otherwise in good health are candidates for this radical surgery.

“An extrapleural pneumonectomy, for the suitable candidate, is potentially the most effective method for disease control of malignant mesothelioma.”

– University of California San Francisco Department of Surgery 

EPP is mostly used in patients with resectable (able to be surgically removed) epithelioid mesothelioma that has not spread to the lymph nodes.

Extrapleural pneumonectomy may improve these patients’ length and quality of life.

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Extrapleural Pneumonectomy Risks and Side Effects

Mesothelioma specialists disagree about the best surgical treatment for malignant pleural mesothelioma.

EPP has been the standard method for more than 30 years to extend life for those with an early mesothelioma diagnosis. However, it poses many risks for even the most ideal candidates. About 30% of patients who undergo EPP are at risk of serious complications.

EPP complications may include:

  • Bleeding
  • Blood clots
  • Changes in heart rhythm
  • Chest fluid build-up
  • Infections
  • Loss of lung function
  • Pneumonia
  • Death

According to the University of California Department of Surgery, About 6% of patients who undergo an extrapleural pneumonectomy die during or immediately after the procedure.

However, UCSF says that the percentage, or mortality rate, is lower at top surgical centers experienced in performing the procedure.

Still, many mesothelioma surgeons say extrapleural pneumonectomy is the best procedure for managing malignant pleural mesothelioma. It delays metastases (spread) of the disease, improves breathing, and, combined with radiotherapy and chemotherapy, it can lengthen life expectancy.

Extrapleural Pneumonectomy vs. Pleurectomy with Decortication

A newer and less risky procedure for pleural mesothelioma is pleurectomy with decortication (P/D). P/D, sometimes called the “lung-sparing” surgery, leaves the infected lung intact while the lining and tumors are removed.

EPP and P/D are similar in that they are both aggressive treatments for pleural mesothelioma. However, some mesothelioma doctors argue that pleurectomy/decortication, while less risky, may also be less effective in removing the cancer.

Because of the pros and cons of each procedure, the oncology community remains divided on which procedure is the most effective in treating malignant pleural mesothelioma. Currently, treatment is determined individually based on the specifics of the case.

A new study published in Updates in Surgery in September 2022 concluded that P/D should be the preferred treatment when feasible because of much better outcomes regarding 30-day mortality (patients who die within 30 days after surgery).

The researchers looked at previous studies involving more than 4,800 patients over 42 years treated with EPP or P/D.

Researchers have consistently found that patients who undergo P/D have lower 30-day mortality and fewer complications after the surgery.

Regardless, the debate over EPP vs. P/D among mesothelioma experts continues.

Who Is Eligible for Extrapleural Pneumonectomy?

Extrapleural pneumonectomy is a technically complex operation usually performed at large mesothelioma cancer centers by thoracic surgeons with extensive experience treating and performing surgery on mesothelioma patients.

Because an extrapleural pneumonectomy involves removing a diseased lung, the remaining lung and the heart must be strong enough to bear the increased load.

Patients with these traits are the best candidates for EPP:

  • Early-stage, localized mesothelioma
  • Good heart and lung function
  • Localized malignancy
  • No cancer in the lymph nodes or spread to other tissues
  • Overall good health

This curative procedure seeks to remove all present cancer in the pleural area. If cancer has already spread to other areas of the body, only palliative care can be offered.

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Extrapleural Pneumonectomy Recovery

Extrapleural pneumonectomy is an invasive and complex surgery, often resulting in significant complications.

Patients typically stay in the hospital for 2 weeks. After discharge, an additional recovery period is 6-8 weeks.

During recovery, patients may experience some of the side effects we listed above. These include blood clots, heart problems, infections, and pneumonia.

Doctors agree that the most effective method for a successful recovery is taking steps ahead of time to prepare for the trauma the body will experience.

The renowned Cleveland Clinic offers instructions that may aid recovery:

  • Improve diet: Eat a “cleaner diet” consisting of foods like fruits and vegetables that are rich in vitamins and minerals to reduce inflammation in the body and prepare for the upcoming shock of surgery. Dr. Kevin M. El-Hayek says to avoid processed food, red meat, and other foods that are difficult for the body to break down and cause inflammation.
  • Exercise: Get exercise, even if it’s just taking a short walk or parking the car farther away from the store in the parking lot. This will increase the chances of walking sooner after surgery.
  • Avoid drugs: Stop smoking, drinking, or using mood-altering substances that could affect sleep or anxiety levels before surgery. Cease any smoking or alcohol consumption that could affect anesthesia.
  • Visit the doctor: See your primary care physician to ensure all your medications are optimally dosed. Your blood pressure and blood sugar should be controlled for optimum surgical results. Higher blood sugar counts will inhibit wound healing, so the more they are controlled, the better your recovery.

A mesothelioma specialist can tell you which treatment options are right for you. Find a mesothelioma doctor in your area using our Free Doctor Match.

Extrapleural Pneumonectomy FAQs

What is removed in an extrapleural pneumonectomy?

During an extrapleural pneumonectomy, an aggressive and complex surgery, surgeons remove the cancerous lung along with parts of the chest lining, heart lining, and diaphragm.

What is the survival rate for an extrapleural pneumonectomy?

Some studies have shown that patients with pleural mesothelioma who have an extrapleural pneumonectomy (EPP) have a median survival time of up to 35.6 months.

Some patients have lived an additional 10 years or even more after undergoing this aggressive surgical procedure.

How can I mentally prepare for a major surgery like an extrapleural pneumonectomy?

Patients should prepare their bodies and minds for a major surgery like an extrapleural pneumonectomy (EPP).

Tips on mentally preparing for EPP surgery include:

  • Learn as much as you can about EPP from reliable medical sources so you know exactly what is going to happen on the day of the surgery.
  • Prepare a list of questions to ask your medical provider. According to anxiety specialist Dr. Zeev N. Kain, studies show that the more information a patient has the less anxiety they will experience.
  • Speak to the anesthesiologist prior to surgery about the plan for pain management.
  • Dr. Kain recommends using guided imagery, breathing techniques, and music therapy prior to surgery and afterward to ease anxiety.
  • Most importantly, have a social support system in place to surround you during your recovery. Loving friends and family are crucial during this time.
Reviewed by:Mark Levin, MD

Certified Oncologist and Hematologist

  • Fact-Checked
  • Editor

Mark Levin, MD, has over 30 years of experience in academic and community hematology and oncology. In addition to serving as Chief or Director at four different teaching institutions throughout his life, he is still a practicing clinician, has taught and designed formal education programs, and has authored numerous publications in various fields related to hematology and oncology.

Dr. Mark Levin is an independently paid medical reviewer.

  • Board Certified Oncologist
  • 30+ Years Experience
  • Published Medical Author
Written by:

Director of Patient Advocacy

Jenna Tozzi, RN, is the Director of Patient Advocacy at Mesothelioma Hope. With more than 15 years of experience as an adult and pediatric oncology nurse navigator, Jenna provides exceptional guidance and support to mesothelioma patients and their loved ones. Jenna has been featured in Oncology Nursing News and is a member of the Academy of Oncology Nurse & Patient Navigators & the American Nurses Association.

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  1. American Cancer Society. (n.d.) Surgery for Malignant Mesothelioma. Accessed on September 29, 2023. Retrieved from:
  2. Cao, C., D. Tian, J. Park, J. Allan, K.A. Pataky, T.D. Yan, (2014, Feb.) A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma. Accessed on September 29, 2023. Retrieved from:
  3. Casiraghi M, Maisonneuve P, Brambilla D, Solli P, Galetta D, Petrella F, Piperno G, De Marinis F, Spaggiari L. Induction chemotherapy, extrapleural pneumonectomy and adjuvant radiotherapy for malignant pleural mesothelioma. Eur J Cardiothorac Surg. 2017 Nov 1;52(5):975-981. doi: 10.1093/ejcts/ezx122. PMID: 28482086.
  4. Cleveland Clinic Health Essentials. (2021, May 18). Scheduled for surgery? Five ways to prepare yourself. Accessed on September 29, 2023. Retrieved from:
  5. Danuzzo F, Maiorca S, Bonitta G, Nosotti M. Systematic Review and Meta-Analysis of Pleurectomy/Decortication versus Extrapleural Pneumonectomy in the Treatment of Malignant Pleural Mesothelioma. Journal of Clinical Medicine. 2022; 11(19):5544. Accessed on September 29, 2023.
  6. General Thoracic Cardiovascular Surgery. (2014, Mar. 19). Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma. Accessed on September 29, 2023. Retrieved from:
  7. Journal of Thoracic Disease. (2018, Jan. 10). Surgery for malignant pleural mesothelioma: an international guidelines review. Accessed on September 29, 2023. Retrieved from:
  8. Journal of Thoracic Disease. (2019, Mar. 11) Extrapleural pneumonectomy. Accessed on September 29, 2023. Retrieved from:
  9. Kain, Zeev N. (2017, Dec. 9). How to mentally prepare for surgery and recovery faster. Accessed on September 29, 2023. Retrieved from:
  10. Magouliotis, D.E., Zotos, PA., Rad, A.A. et al. Meta-analysis of survival after extrapleural pneumonectomy (EPP) versus pleurectomy/decortication (P/D) for malignant pleural mesothelioma in the context of macroscopic complete resection (MCR). Updates Surg 74, 1827–1837 (2022). Accessed on September 29, 2023.
  11. University of California San Francisco Thoracic Surgery Department of Surgery. (n.d.) Extrapleural Pneumonectomy. Accessed on September 29, 2023. Retrieved from:–procedures/extrapleural-pneumonectomy.aspx

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